Oral Health Matters

Richard Watt 00:04

Welcome to Oral Health Matters, a podcast that shines a spotlight on oral health and calls for it to be embraced as a key part of the global public health agenda. I'm Richard Watt, Professor of Dental Public Health at University College London. In this second series of our podcast, I'll be in conversation with leading researchers and policy makers from around the world who are working in the fields of global health or public health, and who are interested in issues of equity, community action and the politics of health. In this episode, we are focusing on the extraordinary geopolitical global landscape we are all experiencing currently, and we'll explore the potential impact of these political changes on global oral health. What are the dangers and threats posed by the policy agendas of populist governments around the world and at this time of fundamental change, are there opportunities for positive change moving forwards? I'm pleased to be joined by two global oral health leaders. Dr Khabiso Ramphoma is a associate professor in the Faculty of Dentistry at the University of the Western Cape in South Africa, and a rising light in global oral health research. My second guest is Dr Bob Weyant, Professor in Dental Public Health at the University of Pittsburgh in the US, and a very experienced and seasoned researcher and policy advocate both in the US and internationally. So, thank you, both of you for joining me in this conversation. What I'd like to maybe start doing is asking you to reflect on what has been the impact over the last 12 months of these unprecedented geopolitical changes that are taking place. How were these geopolitical shifts in policy, in science, etc, affected your work in any way. So maybe let's start with Bob and focusing on the US experience. How has it been for last 12 months Bob?

Bob Weyant 02:14

It's characterized by uncertainty, to be sure, Richard, bordering on chaos at times. We are seeing a lot of volatile policy changes, sometimes long standing, sometimes reversed within days. Public health is getting very much de-emphasised. They're done away with the Oral Health Unit at the Centres for Disease Control. There are lots of implications in funding cuts across the board that have impact on oral health. The National Institutes of Health, there was a attempt to cut their budget by 40% but Congress has tried to restore that in the legislation for funding this year. So, there's just a lot of noise. It's hard to pick up a newspaper every day and try to figure out what's going on and then realise that half of what you read today is going to be changed sometime next week. But it's it makes planning, long-range planning very challenging. And you know what happens when people live in this kind of environment? Coalitions sort of fall apart, but new ones arise, timelines get stretched out on projects, funding becomes uncertain, you know, personnel are lost, workforces are impacted. So, it's pretty hard to characterise what's going to happen in the near future, because it seems to change so much.

Richard Watt 02:15

Okay, so an awful lot going on, for sure. And just maybe just one quick follow up before we move to the global south. Bob, what's your view on inequalities, disparities, social divisions in the US. Is this a time for accentuating these disparities? Or what's your view on that particular angle?

Bob Weyant 02:15

Well, I would characterise it as a direct attack on efforts to continue to sort of focus on decreasing disparities, increase equity, social justice issues. I'll give you some experiences that I have some relationship to. And that is early on last year, there was a presidential order that programs on DEI, you know, Diversity Equity, were no longer going to be supported, and to the point where the administration in Washington threatened to defund university grants if they didn't dismantle their DEI programming. That actually got down to the level of asking faculty to look through their syllabi of their courses and remove things that suggested that content in that course would cover issues around, you know, oral health disparities, equity, etc. So, it's, it's gotten right down into the weeds rather quickly on how these policies are actually being sort of implemented, and the reaction of the universities hoping not to get funding cuts as a result.

Richard Watt 04:59

Well, lots of different angles there. Can we move to the global south and South Africa, you're enjoying your summer at the moment, where the rest of us are freezing cold, but South Africa, I don't know how many miles away from US it is, but your long distance away. But have the governmental changes in US and elsewhere had any impact in your work?

Khabiso Ramphoma 05:22

Thank you, Richard. They definitely have had quite a significant impact on our work. And if you just remember, not long ago, we had the G20 meeting right here in South Africa, and one of the very strong messages that came out was that the global south is really at a crossroads right now, where we faced with world healthcare systems, and we're not only struggling to meet demand, but also slowing the progress of the SDGs and also hitting the economic growth. So here in South Africa, we feel this shifts quite quickly, because these global geopolitical changes have filtered down in practical ways. And of course, as you know, South Africa is known for being one of the most unequal countries in the world, and we have a quadruple burden of disease. And all of this, we see the shift, especially when it comes to funding and research priorities. And of course, over the past year, there's been so much uncertainty, as Bob said, when it comes to international funding, and with that comes so much pressure on short term as well as visible outputs, and this makes it so much harder for long term, especially prevention focused work, which is something that a country like ours needs, and sometimes this agenda pulls towards the global priorities that don't reflect what our communities right here in South Africa are going through.

Richard Watt 06:44

Okay, so really, some commonality there, I suppose what we're hearing is all this uncertainly, politically is important, and the Sustainable Development Goals, the SDGs clearly, are really important about poverty, elimination, about equity, about gender parity, etc. So, some big political issues that potentially are under threat from that global agenda. But maybe could we also think about your health care systems more broadly, Bob just in the US and I know each system has a unique feature, but your current government has it changed entitlements to say, subsidised dental care in your in your health care system? What's the impact been on the actual health care system itself?

Bob Weyant 07:31

Just to set the stage, the United States has a fragmented health care delivery system that's funded through a variety of programs, some public, some private, but there is no universal health coverage in the US, either for medical care or dental care. Where we do have funding that's important for particularly low-income individuals, is the Medicaid program. That's a partnership between the Federal Government and states, so each state will manifest that program in a different way, and that's where you see a lot of diversity in the way the funds are distributed. Who's eligible for dental care funding, public funding, through the Medicaid program. In the last year, there's been some substantial changes in that each state is allowed to come up with certain plans that are approved at the federal level, but several states have now added what's called work requirements for being eligible for Medicaid, meaning that if you're don't have some serious disability, that if you don't have a job, then you don't get access to the health care, the Medicaid plan. It's an unfortunate situation, I mean, it's been used in the years past. It doesn't work well. Dentistry has always been on the outside of the Medicaid program. We are considered a separate program, and because we exist in state budgets as a standalone dental insurance plan for low-income individuals, it's an easy one to cut when budgets come under strain, which they almost always do. So, we're constantly fighting, from an advocacy perspective, to keep that money there so people can access dental care. And then, of course, our dental system, our delivery system, is privatised for the most part, so each dentist will decide individually if he or she will take that funding from Medicaid and use it, you know, or they won't see Medicaid patients. So, Access to care is a huge issue for low-income folks in the US as well.

Richard Watt 09:25

Okay, so a real impact then on access to services, etc, particularly for marginalised potential populations.

Bob Weyant 09:33

Yeah.

Richard Watt 09:34

Moving back to South Africa, thinking about what we've heard about funding changes. Has there been impact on, say, maternal and child health services, HIV prevention, have those type of public health programs been adversely affected in recent months?

Khabiso Ramphoma 09:52

Since the past 12 months, yes, we've seen quite a change in funding for those programs where the US pulled out and organisations such as PEPFAR that were instrumental in supporting HIV and AIDS organisations pulled out as well, and we do see quite a lot of people now. In fact, whenever we have patients right here at the faculty, we have a lot of patients now that are defaulting on their medication because it's not as easy anymore to get hold of their antiretroviral medication. So, we see that every day as we work here at the faculty. And when it comes to maternal and child health services, we're also seeing that it's really the impact. It's, yeah, it's just great.

Richard Watt 10:36

And just thinking, because obviously the changes in the US are significant at a global level. But, you know, I'm speaking from London and our international development budget has also been cut because our government is spending more on defence spending rather than on international development, despite the, you know, the criticism of many of us is that having effect? You know, either UK or EU funding, is that being reduced for countries like South Africa? From your experience,

Khabiso Ramphoma 11:03

From my experience, I believe that we've also seen reductions when it comes to funding from other countries as well. And I know at the moment, the President has been speaking a lot about ways of trying to fund ourselves, and ways of trying to have south to south collaborations. But of course, this will not be overnight achievements. These are things that will take quite a long time to achieve.

Richard Watt 11:30

Well, maybe we'll come back to that point soon, in terms of alternative models are working, because that's an interesting one. But I want to ask both of you one of the very significant first impacts of the new administration in US was funding for WHO. So that the Trump administration removed the US from WHO, and that has had a big effect on WHO activities. Now, Bob, I don't know in the US has that received much media attention? Has that been noted or is that just something that's sort of passed by and people are not really aware of the changes at WHO.

Bob Weyant 12:10

When they first announced, you know, their withdrawal of support for WHO it did make some headlines for a week or so, but only for those folks who are in public health or in, you know, health policy, would this still be something they'd be thinking about, you know, it's completely dropped off of the radar for the average citizen. And that's, I think, because what we perceive as, you know, anything coming from WHO to benefit the US that's negligible in our, you know, our view that we're more interested in the internal policy issues around NIH and CDC and those organisations, but, yeah, it has made a big shock to those in public health, and we're certainly, you know, tracking that to see what the final implications are going to be.

Richard Watt 12:57

Right, thanks. And back in South Africa, WHO presumably a respected organisation in the global south and South Africa. Have you seen any effects on the regional office in terms of their activities Khabiso?

Khabiso Ramphoma 13:13

Yes, so, I mean, this is such an important question, because what we understand it now is that when funding from WHO is also reduced or withdrawn, it's more than just money, but then WHO also offers support for policy development, for activities such as surveillance and, you know, coordination and overall guidance, especially integration into a primary health care activities. And for oral health is also tied to larger problems, and this is something that Taskeen and Habib highlighted, which is that oral health has been historically neglected at global policy levels, even though billions of people suffer from this preventable diseases. So, in South Africa, we already spend very little on oral health and workforce capacity is limited, and majority of our population, which is 80% they rely on public health, and only 20% can actually afford private health care. WHO support has helped to keep oral health on the agenda, especially in linking it to non-communicable diseases as well as primary health care. And when that support fragile programs become even so much harder to sustain, and when broader health fundings falls, this hits oral health the hardest, and we all know that oral health is not protected within other national health budgets. So, yes.

Richard Watt 14:38

Okay, so again, a significant negative impact that's taking place there. Well, I wonder, before we move on to thinking about it's a way forward and how to sort of mitigate these circumstances, one final question to focus on, is a sort of stakeholder analysis, which actors are benefiting or supporting the populist government decisions they're making. Is this just purely a political issue, or are there wider sort of global forces that are pushing these agendas forward? I mean, tricky question, but Bob any thoughts on that one?

Bob Weyant 15:15

Yeah, I think if you accept the notion that the current government's underlying motivation that pretty much permeates all of the policies that they're advocating is to cut public spending on programs that are viewed as marginally important to the class of people that don't rely on publicly funded oral health care or other. And consequently, everything that's happening is to cut public funding so that tax rates can be lowered and impact mostly the higher income individuals, because in the United States, we fund our elections through private donations, and the folks with the most money make the private donations that then lead to the policies that follow. And you can see this, you can draw a straight line to cutting Medicaid funding, to cutting NIH funding, to cutting, you know, all sorts of programs that sending money to WHO, all of that stuff. What's the underlying theme? It's cutting public spending so that when we cut the taxes, they don't result in larger deficits. And that's perhaps slightly cynical, but that's just exactly how I view it, and it certainly seems to fit the data.

Richard Watt 16:27

Right, so that's economic political arguments about privatisation, but sort of deregulation, about free markets. In South Africa is there, I mean, your government clearly has a very different political stance. But those global pressures, are they having impacts in South Africa, that sort of privatisation agenda Khabiso?

Khabiso Ramphoma 16:51

Yes, we see, as Bob just said now, we also see that oral health is treated as something as a by the way, you know, as something that's not a priority. And when these funding cards happen, then we see preventive programs fulfilled the most of the pressure. And for example, what we see here is that things like school health programs and community outreach and health promotion is no longer priority. And these are the things that are set on the side so that the health priorities can just be, you know, your infectious diseases or other global health agendas.

Richard Watt 17:27

Again, a bit of a depressing state of affairs. But maybe as we're moving towards the conclusion of our discussion, we could try and, potentially if we can, look for some ways forward, some positive agendas that we can begin to discuss. So I suppose my next question really is, what can we do about this? What can we do in any sense, to either mitigate or minimize the impact of these changes? Clearly, geopolitical changes are not within our control. But is there anything we can do I suppose? Bob, what's your thoughts on that?

Bob Weyant 18:05

Well, I think the good news is a couple of things. One, I think that the current administration has overreached, they've done their policy development in a way that was not broad based, consensus building. They simply came in, implemented things without very little conversation with the people who were traditionally affected by it, or, you know, the people that typically can weigh in with some authority on whether this policy is a good idea or a bad idea. So now it's percolating to the point where there's a rising sentiment that that these policies are not good for most people, and they really have lost massive amounts of support. As public health is what can we do, we can, you know, we need to get out there and explain why some of these policies are detrimental to the very people that maybe originally supported the administration, and why these sealant programs, fluoridation issues, integrating oral health to reduce, you know, things like emergency room visits and things like that. This stuff is, is sort of the, you know, the ground substance of public health prevention is, we need to think about these things in a way that make it tangible and local for the people that are affected by it. And so that's, I think, where we are now is we're out there, sort of becoming advocates for policy change, but doing it through local interventions, local data, local descriptions of the impact of the policies. And I think it's getting some traction now.

Richard Watt 19:36

Okay, well, that sounds like a potential way ahead, back to South Africa. I mean, you mentioned previously, a few minutes ago, about potential, say, south to south collaborations, in terms of different ways of working, collaborative and international level. Do you want to say a bit more about that, what would that look like, and how could we move that forward?

Khabiso Ramphoma 20:00

Okay, so one thing that we learning through this geopolitical instabilities is that we forced to be innovative. So, in South Africa, there's also real potential for stronger local partnerships. So, if you look at universities right here in Africa, or in South Africa, and collaboration also with Department of Health and other professional bodies and your research institutions. And also, we don't need to always rely on external funding to lead the change, and this opens up that space to collaborate more south to south. And this is also important because it's context specific. So that means that, you know, we all facing these realities together of limited resources, high disease burden and deep inequalities. And we have to find ways of coming together and trying to solve this ourselves. So, if we can position oral health also at the centre of universal health care coverage and social justice, rather than just, you know, and nice to have, then this moment of your political uncertainty could actually become a catalyst for a meaningful change, I believe.

Richard Watt 21:09

Okay, well, and let's just think a little bit more about that. So south to south collaboration, because we historically, you know, we tend to meet in the global north for scientific meetings, mostly our networks are often dominated by global north countries and organisations. What could we do differently that gives more control to the global south on this agenda? What type of partners and things could facilitate that that shift of focus to a south-to-south collaboration.

Khabiso Ramphoma 21:44

We'll have to think differently. And I know we rely so much on the north, so try and have more meetings here, and look at more partners that are in support of the global south context, trying to have more meetings here so that we can collaborate more. I don't know if that answers your question, Richard.

Richard Watt 22:03

Yeah, I suppose, I think it does. I don't know if there's particular one straightforward answer, but I suppose I'm also thinking about organisations like IADR, International Association of Dental.

Khabiso Ramphoma 22:13

Oh, yes. So, I mean, definitely needs more support in terms of I know when we went to the IADR recently, a lot of us from the global south are unable to afford these meetings that happen mostly in Europe, so they can support us in, you know, trying to make sure that we also participate, because these are issues that also affect us in the global south. So that could be maybe to reduce fees for people that come from global south, that's just one of the examples. And more funding perhaps, research funding that comes from such organisations as IADR. And of course, we have our own organisations here that are doing really well. But if you look at South African Dental Association, that is mostly for private practitioners, so we don't have a lot that supports what's happening in the public context.

Richard Watt 23:02

Okay, well, look, thank you very much. So maybe if I try and sort of conclude here, we've had a, I think, a fascinating conversation at this time of uncertainty, time of chaos, volatility, in terms of policy change, public health is under threat in different ways. But I think we've heard from both of you, there is still a role for public health advocacy, for us to look at the evidence of impact, look at the economic arguments of oral health, oral diseases as being a burden to our populations. And we've just heard now that these changes geopolitically might mean different type of arrangements come forward in terms of more south to south independent activity, etc. So, there could be ways ahead that really begin to take on some of these agendas directly. Thanks to our guests, Khabiso Ramphoma and Bob Weyant and to you for listening. I hope you found our conversation interesting. Do join us for our next episode, which will be published in two week’s time. You can also follow the dental public health group on LinkedIn, BlueSky and Instagram. Oral Health Matters is produced by the Dental Public Health Group at UCL, with production support from Research Podcasts and funding from the National Institute for Health and Care Research.